矢状窦旁脑膜瘤的显微外科治疗（附28例病例分析）
|
摘要
目的探讨不同部位矢状窦旁脑膜瘤的临床特点和显微神经外科手术方法,以提高肿瘤的全切率,降低手术致残率和死亡率。
方法本文回顾性分析了吉林大学中日联谊医院神经外科1996年1月至2007年1月采用显微手术治疗的临床资料完整、肿瘤与上矢状窦或重要引流静脉关系密切的28例矢状窦旁脑膜瘤的临床资料,重点讨论肿瘤的解剖学特点、与毗邻重要结构间的关系及显微神经外科手术方法。
结果按Simpson脑膜瘤切除分级标准,Ⅰ级切除7例,Ⅱ级切除15例,Ⅲ级切除2例,Ⅳ级切除4例,无Ⅴ级切除和手术死亡病例。上矢状窦闭塞的患者,术前血管造影检查可见肿瘤周边皮层静脉增粗,形成端端吻合,其中接受Trolard静脉、中央沟静脉和其它大脑上静脉血液逆流,流向蝶顶窦-海绵窦4例,经Labbe静脉流向横窦3例。全部病例均采用显微技术切除肿瘤,术后一过性肢体运动障碍4例,病灶对侧下肢运动障碍2例,精神症状2例,颅内感染1例。上矢状窦完全闭塞、侧支循环充分建立的患者,切除肿瘤及受累上矢状窦后,无并发症发生。26例患者得到随访,随访时间2月~7年,随访时间≤12月2例,13~24月3例,25~36月5例,37~48月6例,49~60月5例,61~72月2例,>72月3例。SimpsonⅠ级切除者随访期内未见肿瘤复发,SimpsonⅡ级切除者随访期内复发1例,SimpsonⅢ级切除者随访期内肿瘤复发1例,SimpsonⅣ级切除者随访期内有3例复发。2例术后出现病灶对侧下肢运动障碍的患者,1例随访期为20个月,肌力由Ⅲ级恢复至Ⅳ级;1例随访期为8个月,肌力由Ⅱ级恢复至Ⅲ级。术前癫痫的8例患者,术后均系统抗癫痫治疗,随访期内6例已停药,癫痫均未再次发作。术前3例存在皮质感觉障碍的患者,随访期内2例恢复正常。2例不完全运动性失语的患者随访期内语言功能均恢复正常。
结论(1)头部CT和MRI检查可以明确肿瘤的确切部位、形态、大小以及是否存在钙化和颅骨改变,为肿瘤的定位及手术入路的选择提供重要信息;(2)术前MRV和DSA检查可以明确上矢状窦的闭塞情况以及上矢状窦与重要引流静脉的关系,术前应用DSA栓塞肿瘤的主要供血动脉可明显减少术中出血,提高手术治疗效果;(3)应用显微技术切除肿瘤是矢状窦旁脑膜瘤的主要治疗手段,显微手术有利于保护肿瘤周围重要组织结构,提高肿瘤的全切率,减少复发;(4)保护重要引流静脉和已经建立的静脉回流通路可减少或避免术中及术后静脉回流障碍所致各种严重并发症;(5)妥善处理受累上矢状窦可降低肿瘤复发率,保持颅内静脉血液回流通畅,减少静脉血液回流障碍所致各种并发症的发生。
Objective: To discuss microsurgical operative treatment of parasagittal meningiomas and crucial points in operation, and introduce the microsurgical experience of improving the rate of total removal parasagittal meningiomas with minimal morbidity and mortality.
Method: A series of 28 cases operated in our department was analysed restrospectively. There were 13 males, 15 females, with age between 26~68, mean age 47.3. CT and MRI were performed in supporting preoperative diagnosis and tumor localization, all patients were treated with microsurgical techniques and histologically verified meningiomas. The presenting features, operative details and complications were documented.
Results: According to Simpson meningiomas resection system, GradeⅠwas achieved in 7 of 28 patients, GradeⅡin 15, GradeⅢin 2 and GradeⅣin 4, surgical effects were satisfying. There was no surgical mortality.
Conclusions: Parasagittal meningiomas represents a difficult surgical challenge. Contemporary microsurgical techniques play an important role in the treatment of parasagittal meningiomas. The preoperative diagnosis results obtained by CT and MRI scan are helpful in selecting the proper approach, microsurgical operation is the best treatment to parasagittal meningiomas with less complications and high life qualities. Good understanding of the anatomy about superior sagittal sinus, application of microsurgical techniques can greatly increase total resection rate of tumor, avoid potential injury to adjacent important structures and reduce mortality. However, palliative operations should be carried out in some cases of tumors apparently invading important tissues such as superior sagittal sinus and important vessels.
方法本文回顾性分析了吉林大学中日联谊医院神经外科1996年1月至2007年1月采用显微手术治疗的临床资料完整、肿瘤与上矢状窦或重要引流静脉关系密切的28例矢状窦旁脑膜瘤的临床资料,重点讨论肿瘤的解剖学特点、与毗邻重要结构间的关系及显微神经外科手术方法。
结果按Simpson脑膜瘤切除分级标准,Ⅰ级切除7例,Ⅱ级切除15例,Ⅲ级切除2例,Ⅳ级切除4例,无Ⅴ级切除和手术死亡病例。上矢状窦闭塞的患者,术前血管造影检查可见肿瘤周边皮层静脉增粗,形成端端吻合,其中接受Trolard静脉、中央沟静脉和其它大脑上静脉血液逆流,流向蝶顶窦-海绵窦4例,经Labbe静脉流向横窦3例。全部病例均采用显微技术切除肿瘤,术后一过性肢体运动障碍4例,病灶对侧下肢运动障碍2例,精神症状2例,颅内感染1例。上矢状窦完全闭塞、侧支循环充分建立的患者,切除肿瘤及受累上矢状窦后,无并发症发生。26例患者得到随访,随访时间2月~7年,随访时间≤12月2例,13~24月3例,25~36月5例,37~48月6例,49~60月5例,61~72月2例,>72月3例。SimpsonⅠ级切除者随访期内未见肿瘤复发,SimpsonⅡ级切除者随访期内复发1例,SimpsonⅢ级切除者随访期内肿瘤复发1例,SimpsonⅣ级切除者随访期内有3例复发。2例术后出现病灶对侧下肢运动障碍的患者,1例随访期为20个月,肌力由Ⅲ级恢复至Ⅳ级;1例随访期为8个月,肌力由Ⅱ级恢复至Ⅲ级。术前癫痫的8例患者,术后均系统抗癫痫治疗,随访期内6例已停药,癫痫均未再次发作。术前3例存在皮质感觉障碍的患者,随访期内2例恢复正常。2例不完全运动性失语的患者随访期内语言功能均恢复正常。
结论(1)头部CT和MRI检查可以明确肿瘤的确切部位、形态、大小以及是否存在钙化和颅骨改变,为肿瘤的定位及手术入路的选择提供重要信息;(2)术前MRV和DSA检查可以明确上矢状窦的闭塞情况以及上矢状窦与重要引流静脉的关系,术前应用DSA栓塞肿瘤的主要供血动脉可明显减少术中出血,提高手术治疗效果;(3)应用显微技术切除肿瘤是矢状窦旁脑膜瘤的主要治疗手段,显微手术有利于保护肿瘤周围重要组织结构,提高肿瘤的全切率,减少复发;(4)保护重要引流静脉和已经建立的静脉回流通路可减少或避免术中及术后静脉回流障碍所致各种严重并发症;(5)妥善处理受累上矢状窦可降低肿瘤复发率,保持颅内静脉血液回流通畅,减少静脉血液回流障碍所致各种并发症的发生。
Objective: To discuss microsurgical operative treatment of parasagittal meningiomas and crucial points in operation, and introduce the microsurgical experience of improving the rate of total removal parasagittal meningiomas with minimal morbidity and mortality.
Method: A series of 28 cases operated in our department was analysed restrospectively. There were 13 males, 15 females, with age between 26~68, mean age 47.3. CT and MRI were performed in supporting preoperative diagnosis and tumor localization, all patients were treated with microsurgical techniques and histologically verified meningiomas. The presenting features, operative details and complications were documented.
Results: According to Simpson meningiomas resection system, GradeⅠwas achieved in 7 of 28 patients, GradeⅡin 15, GradeⅢin 2 and GradeⅣin 4, surgical effects were satisfying. There was no surgical mortality.
Conclusions: Parasagittal meningiomas represents a difficult surgical challenge. Contemporary microsurgical techniques play an important role in the treatment of parasagittal meningiomas. The preoperative diagnosis results obtained by CT and MRI scan are helpful in selecting the proper approach, microsurgical operation is the best treatment to parasagittal meningiomas with less complications and high life qualities. Good understanding of the anatomy about superior sagittal sinus, application of microsurgical techniques can greatly increase total resection rate of tumor, avoid potential injury to adjacent important structures and reduce mortality. However, palliative operations should be carried out in some cases of tumors apparently invading important tissues such as superior sagittal sinus and important vessels.
引文
1. Nakau H,Miyazawa T,Tamai S,et al.Pathologic significance of meningeal enhancement(“flaresign”)of meningiomas on MRI. J SurgNeurol,1997,48(6):584-591.
2. 万经海,李长元,江澄川.脑膜瘤,上海:复旦大学出版社,上海医科大学出版社,2002,1-2.
3. 李敏,韩群颖,孙树功,等.上矢状窦的应用解剖.南京医科大学学报,1997,11(6):580-582.
4. 徐子明,余新光,宋志惠,等.上矢状窦中后部脑膜瘤导致静脉窦闭塞后静脉代偿特点及意义.中华神经外科杂志,2003,19(3):170-173.
5. Oka K, Go Y, Kimura H,et al. Obstruction of the superior sagittal sinus caused by parasagittal meningiomas: the role of collateral venous path ways . J Neurosurg,1994, 81(6):520-524.
6. 范新华,黄翔龙,范卫君,等.CT、MRI、DSA 对脑膜瘤诊断的评价.医学影像学杂志,2000,10(2):75-77.
7. Goldsher D,Litta W,Pinto R, et al .Dural tail associated withmeningiomas on Gd-DTPA enhanced MRI: Characteristics, differential diagnostic value and possible implications for treatment. Radiology, 2006,10(5):273-289.
8. Mattle HP,Wentz KU,Eddman RR,et al . Cerebral venography with MR[J ] . Radiology , 1994 ,178(2) :453.
9. Edelman RR,Wielopolski P,Schmitt F.Echo planar MR imaging. Radiology, 2006,19(5):344-346.
10. Menovsky T,DeVries J.Cortical vein end-to-end anastomosis after removal of a parasagittal meningioma. J Microsurgery, 2002, 22(1): 27-29.
11. Ruehm SG,MR Venography.Eur Radiol,2003,13:229-230.
12. Raco A,Vincenzo E,Lenzi J,et al.Long-term follow-up of intramedullary spinal cord tumors:a series of 202 cases.J neurosurgery,2005,56(5):972-981.
13. 徐子明,余新光,朱儒远.中央回区矢状窦旁脑膜瘤的显微手术治疗.中华显微外科杂志,2003,26(1):28-30.
14. 张锐,张学新,李海波,等.神经导航在中、小型矢状窦、镰旁脑膜瘤手术中的应用.中国微侵袭神经外科杂志,2006,11(4):18.
15. Douglas K,John CF,Bernardo P.Judicious resection from a multicentorreview.Neurosurgery,1998,43,4052409.
16. 倪鸣山,潘昕,朱义文,等.矢状窦旁脑膜瘤切除时上矢状窦处理.中华神经外科杂志,1994,10(4):209-210.
17. 陈桂增,陈国明,宋志惠.矢状窦旁脑膜瘤的显微手术治疗.中华显微外科杂志,2006,29(1):72-74.
18. Sindou MP,Alvernia JE.Results of attempted radical tumor removal and venous repair in 100 consecutive meningiomas involing the major dural sinuses.J Neurosurg, 2006, 105: 514-525.
19. Caroli E,Orlando ER,Mastronardi L,et al. Meningiomas infiltrating the superior sagittal sinus:surgical considerations of
328 cases. Neurosurg Rev,2006,29(3):236-41.
20. Sindou MP, Auque J, Jouanneau E. Neurosurgery and the intracranial venous system. Acta Neurochir Suppl. 2005, 94: 167-75.
21. 魏学忠,李智勇,林少宾,等.矢状窦旁脑膜瘤全切后的矢状窦重建.中华神经外科杂志,1994,10(6):313-315.
22. 向勇,李德康,罗维明,等.矢状窦镰旁脑膜瘤的手术治疗.中国临床神经外科杂志,2004,9(1):59-60.
2. 万经海,李长元,江澄川.脑膜瘤,上海:复旦大学出版社,上海医科大学出版社,2002,1-2.
3. 李敏,韩群颖,孙树功,等.上矢状窦的应用解剖.南京医科大学学报,1997,11(6):580-582.
4. 徐子明,余新光,宋志惠,等.上矢状窦中后部脑膜瘤导致静脉窦闭塞后静脉代偿特点及意义.中华神经外科杂志,2003,19(3):170-173.
5. Oka K, Go Y, Kimura H,et al. Obstruction of the superior sagittal sinus caused by parasagittal meningiomas: the role of collateral venous path ways . J Neurosurg,1994, 81(6):520-524.
6. 范新华,黄翔龙,范卫君,等.CT、MRI、DSA 对脑膜瘤诊断的评价.医学影像学杂志,2000,10(2):75-77.
7. Goldsher D,Litta W,Pinto R, et al .Dural tail associated withmeningiomas on Gd-DTPA enhanced MRI: Characteristics, differential diagnostic value and possible implications for treatment. Radiology, 2006,10(5):273-289.
8. Mattle HP,Wentz KU,Eddman RR,et al . Cerebral venography with MR[J ] . Radiology , 1994 ,178(2) :453.
9. Edelman RR,Wielopolski P,Schmitt F.Echo planar MR imaging. Radiology, 2006,19(5):344-346.
10. Menovsky T,DeVries J.Cortical vein end-to-end anastomosis after removal of a parasagittal meningioma. J Microsurgery, 2002, 22(1): 27-29.
11. Ruehm SG,MR Venography.Eur Radiol,2003,13:229-230.
12. Raco A,Vincenzo E,Lenzi J,et al.Long-term follow-up of intramedullary spinal cord tumors:a series of 202 cases.J neurosurgery,2005,56(5):972-981.
13. 徐子明,余新光,朱儒远.中央回区矢状窦旁脑膜瘤的显微手术治疗.中华显微外科杂志,2003,26(1):28-30.
14. 张锐,张学新,李海波,等.神经导航在中、小型矢状窦、镰旁脑膜瘤手术中的应用.中国微侵袭神经外科杂志,2006,11(4):18.
15. Douglas K,John CF,Bernardo P.Judicious resection from a multicentorreview.Neurosurgery,1998,43,4052409.
16. 倪鸣山,潘昕,朱义文,等.矢状窦旁脑膜瘤切除时上矢状窦处理.中华神经外科杂志,1994,10(4):209-210.
17. 陈桂增,陈国明,宋志惠.矢状窦旁脑膜瘤的显微手术治疗.中华显微外科杂志,2006,29(1):72-74.
18. Sindou MP,Alvernia JE.Results of attempted radical tumor removal and venous repair in 100 consecutive meningiomas involing the major dural sinuses.J Neurosurg, 2006, 105: 514-525.
19. Caroli E,Orlando ER,Mastronardi L,et al. Meningiomas infiltrating the superior sagittal sinus:surgical considerations of
328 cases. Neurosurg Rev,2006,29(3):236-41.
20. Sindou MP, Auque J, Jouanneau E. Neurosurgery and the intracranial venous system. Acta Neurochir Suppl. 2005, 94: 167-75.
21. 魏学忠,李智勇,林少宾,等.矢状窦旁脑膜瘤全切后的矢状窦重建.中华神经外科杂志,1994,10(6):313-315.
22. 向勇,李德康,罗维明,等.矢状窦镰旁脑膜瘤的手术治疗.中国临床神经外科杂志,2004,9(1):59-60.